On the Way to Paramedic in Northern VA

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Thursday, July 28 2005
Hot Potato

Yesterday my transport service partner and I took a patient home to die. This is not his story.

Now, it's customary in the transport company at which I work to switch places each call - Tech (or lead) a call, then drive a call, then tech a call. Fate therefore placed DTs behind the wheel during this transport.

As we rounded the corner to the residence I noticed what appeared to be an adult male lying prone on the slope of a small hill. Huh. Funny place for a nap.

We delivered our patient, got him comfortable and gave report to the hospice folk who rolled in a few minutes later. Time on scene, probably twenty minutes.

The heat yesterday was unusual for this time of year. On Tuesday I passed a time/temp display at a bank, which swore that it was 107F. Wednesday was not far below that, if at all.

We were concerned, therefore, when driving from the residence we spotted the same adult male on the same slope in much if not exactly the same position. Hmmm. Silently DTs and his partner held up their hands before their faces, studying the shapes and flex of the fingers - surely the hands of healers. Our moral imperatives were clear. Besides, this could be something interesting.

We called our dispatchers to tell them we were temporarily offline to investigate a possible unconscious, then parked the rig and strolled over.

The gentleman seemed to be breathing, and after a few "Sir! Wakeup!"'s managed to roll himself over. His distress became evident to our nostrils if not our eyes, for he was the victim of muy cervezas. EMS folk would be quick (and right!) to point out that this was not necessarily the case - ketoacidosis can mimic that odor - but our new friend was forthright in telling us of his predicament, which also included being either kicked out of his home or having no home - difficult to understand.

What was easily understood, though, was that this gentleman needed to get out of the heat. Dehydration was an immediate concern, heat exhaustion a sincere possibility. In the shade, he wasn't in any immediate distress, though. Who to call? My partner and I voted to see if PD might be able to escort this fellow back home (if indeed he'd been kicked out, to smooth things over.) Avoid 911 as it might get the guy in trouble - drunk in public or something. He wasn't being belligerent or offensive, let's keep it civil.

I stayed with our charge while my partner dialed non-emergency. I got to hear our end of it.

"Hi, this is (name), calling about an adult male AOB... what? At Foobus Ave and Wombat Street... Oh."

The operator cheerfully informed him that (County), not (City), should be called. Bye! Well, we didn't have (County)'s number. My partner found the number for their Sheriff's department - that should do.

"Hi, this is (name), calling about an adult male AOB... what? Oh, okay. They said it's a police thing, not a sheriff thing. I'm on hold."

"Hi, this is (name), calling about an adult male AOB... what? No, he's fine, just sitting here and... I'm on hold again."

DTs eyes the Army and Navy Recruitment center across the street. Hmmmm. Nahhh.

"Hi, this... at Foobus Ave and Wombat Street... well, it's pretty hot out and... I'm on hold again."

"Hey, you know, just hang up, the hell with these guys. Sir, estamos no llame la policia, we're not calling the police. Go home. Vaya su casa, okay? Aqui it's too caliente, go home."

The gentleman assured us he would do just that. Probably not but at least he was in the shade.

Sheesh. Next time I'm gonna lie and say we found a bag of money, see what happens then.

Saturday, July 23 2005

Slow to post, because there really has been nothing "on topic". Didn't turn a wheel last two duty nights - not once.

On the transport side, there was a cautionary tale - as usual, some of the details have been changed to protect patient identity.

If you've ever been involved in even a minor fender-bender, you may have had to wear a cervical collar (or "c-collar"). This is an extremely uncomfortable device which wraps around your neck, below the chin, and rests on your shoulders. It keeps your neck from flexing.

Mechanically, your cervical spine is a segmented broomstick with an eight-pound bowling ball balanced on it. If you don't have full muscular control of your neck, or have even slightly damaged the bony structures therein, severe injuries may result to the encased spinal cord. The c-collar prevents that bowling ball of a head from crunching the neck bones. Usually the collar is precautionary, and the hospital can X-ray or CAT scan you and remove it shortly after your arrival. Sometimes they leave it on, and so should you.

A young man, unrestrained (read, "no seat belt") driver in an MVA was boarded and collared by EMTs and rushed to the hospital. The patient had stopped breathing and a tube was inserted. Died on the table but was successfully resuscitated.

ABGs came back - his BAL was somewhere near the 500 mark (read as 0.50, way the hell up there).

Some unspecified time later, the patient regained consciousness and was extremely combative. The details are fuzzy, but the patient did bite through the pilot balloon of his ET tube (deflating the cuff), and ripped off his C-collar. He was chemically sedated and a new breathing tube inserted and a new collar placed.

Later still, the patient again "came to" and again angrily removed his uncomfortable C-collar.

Presto-Chango! Like a magician whipping away a handkerchief to show the rabbit has disappeared, the patient whipped his collar off, and all motor function from the chest down magically vanished. He has only gross motor skills in his arms, no finger movement.

Whoops. A couple of fractures at C6 and C7 which, over time, would have healed. The patient can wave his arms in the air, somewhat. There is no control below that point.

"But DTs," you ask between sobs at this tragic tale, "How can this poor unfortunate breathe?" Ah! The magic of enervation and some well placed nerves. Google "myotome" for the details. And for gossakes leave the collar on until the doc removes it.

Sunday, July 17 2005
You Just Wish

I mentioned, oh, several months back the fact that EMS folk are a superstitious lot. From EMTs at the fire station to nurses on the floor, each healthcare worker believes in Magick. Words of Power include "slow", "quiet", and "calm", and any phrases such as "not busy". During his EMT-B clinicals, working in an ER, DTs was almost assaulted by a nurse after the following exchange (roughly approximated):

DTs: "Wow. Slow tonight, isn't it?"
RN: "Shush, you! Waddya wanna do, jinx us?"
DTs: "Oh, sorry. I just meant it seems so quiet."
RN, preparing to strike: "Aaaaah! Don't say that word!"

It seems more and more, though, that the EMS superstitions are actually embraced - yearned for - by some of us. An interesting phenomenon, if true, and one deserving of study by the mental health set.

Now, superstition comes in many flavors, but it seems to me the three most prevalent are the Let's Explain This, Let's Observe This, and Wouldn't It Be Neat.

Let's Explain This superstitions are those which, say, explain thunder as the sound of bowling mountain gnomes (this is a northeastern thing, Rip Van Winkle-y, so left coast folks might not get it.) Any particularly strange explanation supported by zero evidence - balancing eggs on Midsummer day, Aussie toilets flushing clockwise, etc. belong to this category. See Snopes and The Straight Dope.

Let's Observe This superstitions arise from noting that, oh, more births occur during a full moon (not true, according to the RNs in the several OB/GYN wards DTs did time in), or that Fridays are Car Crash Days. Births which occur during a full moon have believers shouting "Aha! See!", while those at any other time are conveniently overlooked. Friday the Thirteenth problems and "these things happen in threes" - air crashes, train wrecks, etc. all fall into this category.

Now, heretofore I was unaware of the "Wouldn't It Be Neat" category. But it seems that some people in EMS actually want things to be true, and don't even wait for the lopsided empirical evidence of the Observe This type of superstition to accrue.

We refer of course to the baseless rumour that DTs is in fact the Angel of Death, based merely on two (2!) incidents that just happened to be the last two calls. Obviously, those purporting this base slander genuinely wish it were true.

Each individual had come to their end long before we were summoned - don't think DTs is using his Medic Powers for Evil, for he is Pledged to Good - and in one case the problem was self-inflicted. Yet, this slim "run of calls" has his Devoted Crew grasping at straws.

"Someone watch DTs - if he sneaks out of the station, we'll get a dead guy call ten minutes later";

"No calls yet - didn't you finish someone off on the way in to work tonight?";

"Say, we could really use a call - disguise your voice and phone the cops with a clue so they can find the body and call us".

Harumph. Man's Best Friend indeed. They haven't a leg to stand on. I mean, it's not as if there were three in row; that'd be entirely different...

Monday, July 11 2005
Hat Trick

The fun thing about working in patient transport is that you are in this big ol' damn ambulance when you're driving around. When Tragedy Strikes, vehicle-wise, you are in a fine position to do something about it, should you so choose. Actually, being a bambulance, you kinda-sorta-gotta.

Case in point. At this time of year the DC area is humid, hot, dank, sweaty... and prone to sudden thunderstorms. One struck Wednesday, causing torrential but brief downpours in the area. The plot thickens.

On the Capital Beltway we happened upon a scene of Chaos and Trauma, to whit: Skid Marks leading to the side of the road; An Unhappy Vehicle, resting on it's driver's side door and facing against traffic; Four Fellows standing next to same.

DTs and his partner determined there were no EMS on scene, just yet. Flip on lights and pull onto shoulder.

Now, it turns out three of the fellows were facing a fourth. Naturally, (he says) one would anticipate that the fourth person was the Leader. As such, we address our questions to him.

"Hey, anybody hurt here?"
"No, no."
"Anybody still in the vehicle?"
"No, no."
"Any other vehicles involved?"
"No, no."

"Everybody okay?"
"Si, si."

Oh dear. Okay, first things first.

"Everybody please, it's still raining. Let's get into the ambulance and wait for the police."

And into the bambulance we go. And why not? Work 'em up. Were they wearing seat belts? Why yes, it turns out, all four of them were - in that pickup truck. Ooookay.

Suddenly two of our guests develop neck pain; another develops wrist pain; yet another finds he has back pain which shoots down his leg... ack! (Typical reaction: Fine during emergency, once relaxed find out something's wrong - adrenaline is wonderful for what it does.) LET'S dial 911 again, shall we?

EMS Proper arrives; we turn into Fast Food Medics.

Take patient information. Do you have allergies with that? Have a collar. Put down backboard onto cot; place patient; a smear of spider straps; a soupcon of head block; a twist of tape and slide them out the end of the unit onto a County cot.


Fun! No one was seriously hurt, but due to mechanism of injury they all needed to be checked out, and well done on them to avoid the "patient refusal" syndrome.

Sunday, July 03 2005
Maybe Lose the Hood and Scythe?

Not too long ago we had another "theme" day. Theme days pop up fairly regularly in EMS - Car Crash Day, Pedestrian Struck Day, Baby Delivery Day. The word "day" is of course used loosely. Many of our calls are at 2:30am where the patient suddenly decides that the leg pain they've been experiencing for three weeks suddenly needs attention ("It Can't Wait Another Week" Day).

The particular theme of our day, then, was Patient Refusal Day. To all those who participated, thank you! You made it another wonderful event. The ad campaign, "C'mon out to Northern Virginia, dial 911, then refuse to be examined or transported! Bring the kids!" was especially effective.

First call: Middle-aged male, syncopal episode in a public place. We arrive, he's vomited down the front of his shirt but is now alert and awake - and "fine, fine. I don't wanna go to the hospital."

"Sir, you passed out. You ever do that before?"

"No, nah, it never happen before."

"Well, you know, that's not normal, passing out like that. Maybe we should get looked at."

"Nah, hate hospitals. I go if I pass out again."

Many bartenders will serve you drinks as long as you can stand and coherently order them. As long as an adult is coherent with EMS, they may refuse treatment. We'll try to talk them into going, if we think it's really necessary, but we can't force 'em.

There are of course exceptions to that - for instance, we can have PD arrest suicidal folk, then treat them once they're in custody - and tricks - if "I don't wanna go!" is bleeding heavily, just wait until he passes out, because it's now "implied" consent. And so on.

Now, if we get a call for something minor, tiny, nothing - a cut finger - we never try to talk someone out of going to the hospital. If that's what they want to do, we're happy to take them. We do however point out that going by ambulance does not bump them up the line to be seen - not at all.

Similarly, if someone simply wants to be "checked out" - feeling dizzy or something - we're glad to do that, too. When asked, "Should I go to the hospital?", we can't say "Yes" or "No" because we're not docs. We can say, "If that's what you want to do, we're right here to take you".

Anyway, so it went on Patient Refusal Day. The guy who fell off a roof and dislocated his shoulder - "Nah, I'll go home and rest a while,"; the mom whose kid passed out at the mall, "Well, we keep an eye on her, taker her in if she don't feel well soon".

Over and over. Got to where we climbed into the unit and sniffed our underarms, wondering how we were offending these fine folk.

Oh well. Perhaps next week's Iron EMS ingredient will be: "OB/GYN". Whee.

Saturday, July 02 2005
Laughing, I suppose

We are certainly some strange folk, in EMS.

We left a house where "great-uncle Fred" hadn't been seen since retiring last night. Turns out, well, he'd had a few medical conditions he may have been ignoring, and died sometime in the night. Not knowing this, dispatched to a "stoppage of breathing" call, we rushed in with our paraphernalia, four of us on the bambulance and several from the wagon (dispatch will if they can send a wagon on such a call, in the event we need more hands for CPR, etc.)

Nothing to be done. The departed had been down for some time based on rigor and lividity. Call the police, and hang around until they show up on scene. All deaths not attended by a physician or occurring in a hospital are "crime scenes" until cleared by the PD. Sensible. Family sad but not surprised or inconsolable.

And what do we all do, hanging around thus? Well, neighbor Dad and his three- and five-year-old sons had waved at the pumper as it roared into the street. Go outside and make happy with the kids!

The youngest was much too shy to leave dad's shoulders, but the older proudly wore an engine crew's helmet as he sat in the cab and pushed the buttons he was shown (surprise! This one's the air horn). I swear his grin was this big. Fortunately we carried in the bambulance some plastic toy fire helmets and stuffed animals. He and his brother seemed quite pleased to have them, when time came finally for them to dismount and we be on our way.

And it occurred to me, as we cleared the scene after PD arrived - you know, that was righteous. What better thing to do, but play with kids after leaving the scene of a not-entirely-unexpected family tragedy?

Now, it followed to ask me self, When exactly would such a thing seem strange? When first I ran EMS, I played imagination games: What if? If this then...? How would...? It always seemed, since we were all about life, that a death scenario was going to be the biggy, the deep dark heads-down heavy-step past the cameras to the unit "no comment" call. I dreaded such a call.

Harumph. DTs remains "death free" lo these many years - I've come to scene for dead folk, and I've run folk who are dead (but we worked 'em), and turned over to the ED folk who've later died. Never put a live patient into my unit and had 'em die on the way, though. Odd pride. Off topic. Nevertheless, death is just one of those things you get used to. For other folk, I mean.

We speak fondly of a particular suicide - "He unloaded the clip and just put one in the chamber to do himself," we say, and the other EMS folk say, "Wow, what a nice guy!". If the weapon were full-clip it would be more unsafe. Very considerate. And I think, "Wait a minute - this guy killed himself, and here I am complimenting him on technique."

But that simply helps to illustrate the odd viewpoint of EMS, I guess.

A HUGE thank you to everyone who offered congrats, public and private, on me EMT-I. You've earned yourselves a free downgrade in needle size on your next IV... :-)


Posted Wednesday, August 10 2005 22:33  Site Meter